How Toxic Stress Is Making St. Louis Sick

Feedback about Alive and Well STL, captured by an artist during a community meeting.

Feedback about Alive and Well STL, captured by an artist during a community meeting.

A website called BetterDoctor.com just ranked St. Louis the 17th healthiest city in the U.S., mainly because it’s so easy to find a great doctor here and so many of us have health insurance.

But for those who don’t, the verdict’s just the opposite.

The Saint Louis Regional Health Commission makes sure uninsured city and county residents ages 19 to 64 (the famous coverage gap) find health care. “We’re doing a very good job of getting people into our health centers,” says CEO Robert Fruend Jr., “but we still have a ton of people getting diabetes, hypertension... We're just not a very healthy community. About 60 to 70 percent of the people on our plan have at least one chronic disease.”

And now he knows why.

Last spring, the RHC’s Community Advisory Board—a group of people with on-the-ground experience in public health and social issues—reviewed the 40 Alive and Well STL radio shows RHC had produced since the previous August. The shows had been geared to hit St. Louisans’ most frequent health problems, including hypertension, diabetes, heart disease, and depression, and the board was wondering whether it was now time to turn to a different strategy. But as they reviewed the topic list, board chair Joe Yancey, executive director of Places for People, and Serena Muhammad, from the St. Louis Mental Health Board, traded looks.

The most common chronic problems shared a single root cause: toxic stress.

Yancey and Muhammad had both read the research (which has exploded in recent years) on the health effects of childhood trauma and other kinds of toxic stress. And they knew people living in poverty in St. Louis were exposed to that kind of stress regularly. Months later, after Ferguson, it ratcheted higher. “When the St. Louis Business Journal publishes an editorial headlined ‘Fear,’” you know we’re probably not ranking high as a healthy community right now,” Fruend remarks.

But the problem’s not unique to St. Louis, and it didn’t start last summer.

Trauma in Childhood; Chronic Illness in Adults

A decade ago, researchers at the Centers for Disease Control and Prevention began releasing findings of the Adverse Childhood Experiences Study. Results from more than 17,000 people (and this was not a group of people living in poverty with no health insurance) indicated that “early experiences can have profound long-term effects on the biological systems that govern responses to stress.”

Ten years and countless studies later, we understand the biochemistry.

Toxic stress in childhood makes people vulnerable to chronic disease—hypertension, diabetes, heart disease, depression—in adulthood. “Your body reacts to trauma and toxic stress in a certain way,” Fruend says. “Blood pressure and blood sugar go up” as the stress hormones are released. If you perceive a threat all the time, your body stays worked up.”

Problems once dismissed as genetic or lousy diet are far more closely linked to trauma (abuse, neglect, parental abandonment, violence, homelessness, a parent struggling with addiction or mental illness, a parent in prison) and the cumulative stress of living in poverty, watching seven fights a day at your school, going home to hear gunshots at night.

Wealthy families experience plenty of trauma and toxic stress, too, but poverty is a risk factor and can exacerbate the effects. “There are parts of our community going through more stress than others,” Fruend points out. “And ironically, those are the folks least able to access the resources that can help them through it.”

Sometimes they’re also the least willing. Maybe they’re afraid they’ll risk losing their job by admitting that they’re going through a rough time, grieving or feeling the aftershock of trauma. They don’t want anyone to think they’re weak, or their judgment is compromised. Some people equate mental illness with demon possession. Some just don’t know where to go for help. “If you have a problem with your heart, you go to the cardiologist,” Fruend says. “But if you’re heart is broken, you think you have to tough it out.”

Becoming a National Model

After its epiphany about toxic stress, the RHC board set itself a new goal, one a lot more complicated than teaching people about nutrition, exercise, and screenings. Alive and Well STL wants to make St. Louis a national model of a “trauma-informed community.”

Kansas City, Mo., is already pushing toward trauma-informed care, and New York has trauma-informed courts, and Washington has trauma-informed schools. But the RHC wants to spread public awareness through the community, training laypeople as ambassadors and teaching professionals to look for toxic stress as an underlying cause in a variety of problems.

Shouldn’t healthcare professionals already know this?

“Some do,” Fruend says. “But when you have 10 or 15 minutes per patient, you’re dealing with the symptoms. One of the docs that works with us said, ‘After five or six visits, if I can’t figure out what’s going on I shut the door, look at my patient and say, “Who hurt you?”’ I said, ‘What if you started with that?’”

The idea isn’t to skip the tests and jump to the couch, he adds quickly. “But they could do both at once. Rule out the most life-threatening possibilities with tests and at the same time, ask people what’s going on in their life that could be contributing.”

What Does a “Trauma-Informed Response” Look Like?

Here’s an example from a high school in Walla Walla, Washington. A child loses his temper and cusses out his teacher. Instead of instantly expelling the child, the principal sits him down and says calmly, “Wow. Are you OK? This doesn’t sound like you. What’s going on?” The principal goes on to tell the boy he looked really stressed and ask him how much anger he’s feeling.

Here’s a St. Louis County example that's not “trauma-informed”: A 12-year-old boy got mad at his teacher and made a slashing gesture with his hand, as though he held a knife. Instantly expelled this past November, he will now receive only five hours of schooling a week (from Fruend's wife) until May and spend much of his time unsupervised, because his single mom has to work. What’s going on in his life that caused the sudden behavioral problems? “Doesn’t matter,” Freud says. “The kid’s a disruption. He violently threatened a teacher. He’s out.

“What do you suppose will happen to him?” Fruend continues. "Now, multiply that by hundreds. And we wonder why our community is not well?”

What you can do:

*Become an ambassador for the cause. “We won’t be able to hire enough mental health professionals to help everyone through this,” Freud says. “We need ambassadors.” If you’d like to learn more and/or help, stop by the Alive and Well STL open house at the Richmond Heights Community Center, 8001 Dale Ave., on January 29 between 8: 30 and 11 a.m. (Don’t expect to dunk a donut; refreshments will be healthy.)